901 Form

Gender Affirming Services (Transgender Services)
Prior Authorization Request Form #901

Medical Policy #189 Gender Affirming Services (Transgender Services)

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the service request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations.

Complete Prior Authorization Request Form for Gender Affirming Services (901) using Authorization Manager.

For out of network providers: Requests should still be faxed to: BCBSMA Members: 888-282-0780

Medicare Advantage Members: 800-447-2994

Patient Information Patient Name:

Today’s Date: BCBSMA ID#:

Date of Treatment: Date of Birth:

Surgical Date:

Physician Information Facility Information Name:

Name:
Address:

Address: Phone #:

Phone #: Fax#:

Fax#: NPI#:

NPI # if applicable:

Diagnosis Codes: Diagnosis Codes:

Anticipated procedures: (check all that apply)

Facial Feminization or Masculinization
Please list procedure codes being requested:

Mastectomy and/or creation of a male chest for transmasculine or gender diverse members
Please list procedure codes being requested:  Breast augmentation for transfeminine members
Please list procedure codes being requested:  Genital surgery for transmasculine, transfeminine or gender diverse members
Please list procedure codes being requested:  Surgical revision to correct a functional impairment Please list procedure codes being requested:  Vocal cord surgery (Wendler Glottoplasty) for transfeminine members Please list procedure codes being requested:  Other Please state the service being requested and please list the procedure codes:  Please indicate if procedure will be performed: Inpatient  or Outpatient 

Physician’s signature:____

Please include supporting clinical documentation for requested procedures.
Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.